Diabetes

Diabetes mellitus is a serious disorder caused by an insulin deficiency. Insulin is a hormone produced by the pancreas that is secreted into the blood after eating. Its roles are twofold: to promote the storage of glucose, as ready to use glycogen and for later use as fat, and to stop glucose formation from stored body fats; and to promote the uptake of amino acids and the manufacture of these into proteins.

There are two types of diabetes mellitus. Type I, also called insulin dependent diabetes, is caused by very low or absent insulin secretion. Patients with Type I diabetes will die if not treated with insulin. Type II, or non insulin dependent diabetes, is caused by inadequate or delayed insulin secretion relative to the needs of the patient. Many of these patients live without insulin treatment. Type II diabetes is by far the more common.

Diabetes mellitus affects both cats and dogs. The disease can be caused by infection or inflammation of the pancreas, by genetic causes, immune system attack of the pancreas, as a by-product of other diseases, and, rarely, as a side effect of some drugs. Obesity vastly increases the risk of your pet contracting diabetes.

In Australia, vets are seeing more and more cases of Type II diabetes. This is mirroring the experience of our colleagues in human medicine, and probably for much the same reasons — just like us, our pets are becoming fatter and more sedentary than ever before.

Clinical signs:

Diabetes mellitus is usually first seen in middle age (4-14 years) in cats and dogs. Diabetic pets usually eat a lot but lose weight, drink a lot and urinate a lot. Cataracts develop quite rapidly in dogs with poorly controlled diabetes, leading to blindness.

As the untreated disease progresses, pets develop ketoacidosis and become very sick, developing anorexia, vomiting, weakness and lethargy. At this stage the diabetes has become a serious life threatening illness.

How is diabetes diagnosed?

Diagnosis of diabetes mellitus involves measuring glucose levels in urine and blood. A full urinalysis and blood screen is performed to diagnose the diabetes, assess the severity of the disease, look for underlying causes of diabetes and to examine for secondary problems associated with the diabetes, for example, urinary tract infections.

Treatment protocols:

Treatment of pets with uncomplicated diabetes involves dietary changes, the use of injected insulin, and regular monitoring of blood glucose levels in the hospital. Where required, insulin therapy is lifelong for most patients, and can involve once or twice daily injections (administered by the owner — we teach you how to do this). Some cats can be managed with oral medication rather than insulin.

Soft, moist foods are avoided. Pets that are not overweight are fed a diet they will reliably eat that has a constant calorie content. Overweight pets are fed on special weight reducing diets.

The ideal diet is high in fibre as this helps stabilise blood glucose levels, and will be low in fat and high in complex carbohydrates. Set feeding times and amounts are determined for your pet and are fixed in relation to insulin injection times. Exercise levels for your pet need to be kept consistent or will interfere with the stability of your pet’s blood glucose levels.

Initial stabilisation on insulin therapy requires day hospitalisation and the taking of blood glucose levels throughout the day. This may need to be repeated every few weeks until things are stabilised, then every few months or whenever a problem arises.

At home monitoring involves assessing levels of drinking and urinating, eating and body weight.

Hypoglycaemia, or low blood glucose, can occur if too much insulin is given or if your pet doesn’t eat normally or uses more glucose than usual, for example, through excessive exercise. The most obvious sign of this is weakness or lethargy, which will improve rapidly if a readily absorbed glucose source such as honey is given. Left untreated hypoglycaemia can result in coma or death.

Ketoacidotic patients — the really sick ones — need hospitalisation and intensive treatment with intravenous fluids and medication to get them past this life threatening stage. These patients are harder to initially stabilise on insulin, but once past this are treated in the same way as uncomplicated diabetic patients.

Entire females should be speyed when stable, as cycling makes management of their diabetes difficult, and pregnancy is strongly recommended against, it is difficult to maintain and can cause many problems for the mum.

Come Home Spot is a community initiative by Alpine Animal Doctors that aims to see every pet in the Alpine Shire microchipped so they can be reunited with their family if they get lost.

There are almost six million pet dogs and cats in Australia. Every year thousands go missing. People move and Spot or Kitty decide the new place is not to their liking and set off to head back ‘home.’ They’re frightened by fireworks or thunderstorms and run away, to become lost and confused.

All too often these lost pets never find their families again, ending up at Council Pounds or animal shelters. Some may be rehomed but for many their fate will be euthanasia. The lucky ones — those whose owners had the foresight to have them microchipped — are quickly returned to their families.

Implanting a microchip should be one of the first things you do when you bring a new animal into your home. In fact, it’s a legal requirement in most states. From 1 January 2012 microchipping has been compulsory for all dogs across the whole of Australia, but microchipping legislation generally applies only to dogs and cats, and only to those born after the introduction of the legislation. That still leaves many thousands unprotected.

At Alpine Animal Doctors we have an ongoing program that aims to see every pet in the Shire — from Myrtleford to Mt Beauty — microchipped by 2020. This is not about revenue for our practice. Vets don’t make money from microchips, the low one-off lifetime fee really only covers the costs. It’s about protecting all of those who can’t protect themselves.

Put simply, if every animal owner had their pets chipped, and kept their registry details up to date when they moved house, we might never again see a stray dog or cat have to be put down because we can’t find their owners.

Microchipping is an extremely simple, safe and inexpensive procedure. Just call the hospital and we’ll do the rest.

This page was updated July 2017. The artwork featured is from the Deviantart community and was created by Devianart member Brandimuffin. Copyright is owned by the artist. Please do not download or share it without permission. It is reproduced here under a CC license. You can find the original and other work by Brandimuffin here.

Genetic research at Alpine Animal Doctors

In keeping with our mission to build a true centre of excellence for the delivery of animal healthcare, we do more than offer innovative and top quality veterinary services to our clients and patients. At the hospital we have our own small research centre, where we undertake projects aimed at advancing veterinary treatments for animals everywhere.

Dr. Bek collaborates with genetic research groups around the world and is credited with the discovery of a previously unknown genetic disease affecting Tenterfield terriers (Congenital Hypothyroidism with Goiter, or CHG). Working with Professor John C. Fyfe, D.V.M., Ph.D., Associate Professor of Microbiology and Molecular Genetics at Michigan State University over a period of two years she also played a role in the successful development of a buccal swab for DNA testing for carriers of the disease. The majority of breeding stock of Tenterfield Terriers in Australia has now been tested and carriers are being identified, making it possible for CHG to ultimately be eliminated from the breed.

Although this kind of research takes precious time out of an already very busy schedule, at Alpine Animal Doctors we think it’s important that veterinarians make the effort to get involved in the wider advancement of veterinary science, and in continual further education and study to ensure we stay abreast of the latest innovations and developments in veterinary medicine.

By encouraging all of our staff to continually engage in learning and collaboration with others across the world this involvement in research and study ultimately directly benefits our clients and patients.

The different pet vaccinations explained

The different types/levels of vaccination for dogs and cats are listed below. Beginning with the C3 (for dogs) or F3 (for cats) Core vaccine each vaccination is additive, i.e., a C7 canine vaccine contains the C3 core plus C4 and C5, providing protection for all of the diseases covered by individual vaccines. Your pet will need only one injection regardless of which vaccination level is appropriate.

FIV (feline immunodeficiency virus) can be optionally included in any of the above.

If you have further questions regarding which vaccination is most appropriate for your pet please call us on 5756 2444.

How often should I vaccinate?

For many years an annual booster vaccination was the standard for dogs and cats. More recently, as modern vaccines have become more and more effective, some studies have shown that an annual vaccination is not always necessary. Research suggests that the duration of immunity (DoI) of many of the current vaccines varies, and may provide protection for considerably longer than twelve months.

Current guidelines suggest that, after the initial vaccination series and the one-year booster shot, in most cases core vaccines could be administered every three years (trienally) rather than annually. In some cases even less frequent vaccination may be appropriate. However, variations in the titre level and duration of antibodies can be extreme in individual animals. The only way we can accurately determine if your pet has sufficient antibodies remaining from previous vaccinations is to run a titre test. We can do this in the hospital’s own pathology lab but it is unfortunately more expensive than the vaccination itself.

We rely heavily on local factors, individual patient needs and the circumstances of the client to dictate what kind of vaccination is required and how often it should be repeated.

In most cases we continue to recommend an annual vaccination, for a number of reasons. One is that although less frequent vaccination is often suggested as saving money for the pet owner, the reality is that the higher cost of a triennial vaccine is such that the cost of vaccinating every three years is actually much the same as annual vaccinations.

Another is that the triennial guidelines apply only to core vaccines. The important non-core vaccines still require annual boosters.

Finally, and importantly, clients who feel their pet needs only the basic core vaccine and opt for the triennial vaccine means Dr. Bek may see your pet only every three years. In animal years that’s a very long time between checkups — roughly 20 years. It’s like you visiting your doctor for a check-up just once every two decades.

The degeneration of organs that can occur in those three years is phenomenal, and often irreversible. Heart conditions, dental disease and kidney failure can easily develop within a six-month period and, left untreated, progress to the point where it becomes very difficult, if not impossible, to treat.

If pets are seen yearly we can diagnose health issues so much easier and can often slow, if not reverse, some life-threatening conditions.

The few minutes you and your furry friend spend in the consulting room for that annual vaccination are one of the most important aids to helping keep your pet healthy. We don’t just give your pet his or her vaccination. They get a thorough check up too and it’s surprising how often we pick up latent diseases and/or symptoms that, treated early, can avoid far greater trauma and cost in the future. It’s also an opportunity for us to discuss with owners any changes or anything out of the ordinary that may have occurred in the life of their pet which might point to underlying or developing health issues.

Our policy is to never over vaccinate and to always use current best practice based on all available research. We will fully discuss with you all of the pros and cons of the various immunisation options available to ensure you are fully informed.

Whether you decide on annual or triennial vaccines, the most important thing you can do is to make sure that your pet receives an annual check up at the hospital.

When should I desex my pet?

Traditionally most veterinarians have preferred to desex dogs and cats shortly before they enter puberty, at around six months of age. The thinking has been that six months is not too young, not too old, and an age that pre-dates the advent of sexual maturity, with all of the behavioural issues that can bring. Most vets would still see that as the ideal age, for most pets, and in most circumstances.

The success of public education programmes promoting desexing to reduce the number of unwanted dogs and cats, and the introduction of State and local laws mandating compulsory desexing for animals sold as pets or adopted from shelters has seen the average age for desexing steadily reduce. In many cases shelters and Humane Societies are now routinely desexing animals before they go to their new homes, sometimes at as young as 8 or 9 weeks.

As far as the spaying or neutering procedures themselves are concerned there is no inherent problem in desexing an animal even at this very young age. Young puppies have very strong recuperative powers and are generally running around or looking for dinner just a few hours after their operation.

However, research in recent years has seen a growing body of evidence that desexing too early can potentially affect the long term health of your pets, in some cases quite severely. Early neutering (males) and spaying (females) has been suggested as one potential causal factor in the areas of orthopaedics, cancers, life expectancy, behaviour and a wide range of other negative health outcomes. The findings of some studies have set alarm bells ringing amongst progressive veterinarians, many of whom are now rethinking the long established ’standard’ protocol of 6 months and fine tuning their desexing age recommendations based on a range of factors, including gender, breed, genetic markers etc.

There are two factors at play here, both linked to desexing. The removal of the gonads (testicles or ovaries) — which occurs when conventional methods of desexing (castration or ovariohysterectomy) are used — and the consequent loss of the hormones produced by these reproductive organs is one. See here for more comprehensive coverage of this. The second is that this loss of steroid hormone production, particularly when conventional desexing is performed prior to full physical maturity, has also been implicated in delayed closure of the growth plates, which can lead to significant changes in physical growth patterns in desexed dogs compared with unaltered dogs.

In a growing dog (or cat) various hormones, including the sex steroid hormones, help control the genetically pre-determined lengths and weights of bones. The closing of the growth plates should occur at full physical maturity, preventing further growth. If closure is delayed by early desexing it can result in alterations to body proportions. Dogs spayed or neutered before puberty can often be taller, have longer limbs, lighter bone structure, narrower chests and narrower skulls than intact dogs of the same breed.

These changes in growth patterns can lead to significant orthopaedic health issues. For example, in one study of 203 agility dogs the tibia and radius and ulna were found to be significantly longer than the femur and humerus, respectively, in dogs spayed or neutered prior to 8 months of age when compared to intact dogs. Another study, conducted at the University of California, Davis, examined the medical records of 759 Golden Retrievers treated over a 10-year period and found a greater occurrence of hip dysplasia (1.5x) and cranial cruciate ligament tears in desexed Golden Retrievers compared with their intact counterparts. That research found the health risks were greater for dogs who were desexed when younger than one year old.

Several studies have concluded that neutered and spayed dogs also have a significantly higher prevalence of CCL rupture, and are three times more likely to suffer patella luxation. In recent years there have been some 180 different studies on the health effects of desexing. Most have found some correlation between early desexing and negative health outcomes of various types and degrees of severity.

These negative health issues can affect all breeds but, for the most part, seem to primarily occur in large and giant breeds of dogs, with some breeds far more likely to be affected than others, including Golden Retrievers, Rottweilers, Bernese Mountain Dogs, German Shepherds and Boxers. Even within those at risk breeds individuals may or may not be affected. Conversely, individual animals within breeds thought to be unaffected by abnormal growth rates, such as toy breeds, may suffer some of the issues that generally affect larger breeds.

As is so often the case with medical research, even after many studies, large and small, there is rarely a definitive black and white answer. However, here at Alpine Animal Doctors we think that, overall, the weight of evidence against early desexing is compelling enough to warrant us taking it into account when making recommendations for desexing.

We have no ‘standard’ recommended protocol on the age at which you should desex your pet. Each patient is evaluated individually and recommendations made only after taking into account a range of factors. We will of course consider the gender of your pet, and any genetic propensity of its breed to suffer higher incidences of those health issues related to desexing. In addition we will also look at your pet’s growth rate at the time of examination (not all dogs grow at equal rates). We may also look at diet and ‘lifestyle’ issues such as exercise levels, both of which play a part in growth rates, before making any recommendation.

In very general terms however we might suggest that toy breeds can be safely desexed at around 7-8 months old. Medium sized dogs may be best allowed to go through puberty and reach physical maturity, at about one year of age. For larger breeds physical maturity may be reached at around 18 months, while giant breeds can still be growing at two years old.

The downside of waiting until physical maturity is reached is that your pet will have entered sexual maturity prior to being neutered or spayed. Most of our clients find this easy to manage for a few months but it may be challenging for some pet parents or some households. If this is the case you may wish to consider vasectomy for male animals or an ovary-sparing spay (OSS) for females.

These alternatives to the conventional castration or ovariohysterectomy (OHE) retain the testicles or ovaries which are responsible for the production of the hormones that are now known to play such a large part in healthy growth. With these intact it is safe to desex at an earlier age while still avoiding the potential long term health issues. You can learn more about the pros and cons of castration here and of ovariohysterectomy versus ovary-sparing spay here.

In all cases, the wishes of our clients are paramount. We understand that sterilising your pet is an important decision and we welcome any questions you may have. If you prefer to desex earlier, using conventional surgical techniques, we will of course respect your wishes.

At Alpine Animal Doctors we have been taking the most current scientific information into account — and offering alternatives to the conventional ‘one size fits all’ approach to desexing — for a couple of years now. Around 50 to 60 per cent of our clients are opting to delay desexing, particularly spaying of females, until their pet is fully grown. We are already seeing some encouraging signs that our re-evaluating of age recommendations looks likely to lead to a healthier life for our patients, with less need for veterinary intervention as they grow older.

For additional information, see OHE or OHS — which is best for my female dog? and Castration or Vasectomy — which one is right for my dog?

Traditional spay or Ovary-sparing spay?

The choice between conventional ovariohysterectomy (OHE) or hysterectomy (ovary-sparing spay or OSS) is not black and white. Both procedures have their advantages and disadvantages. Perhaps one day we’ll have a simple and safe contraceptive pill for pets but, until then, there is unfortunately no single ideal solution. The procedure you choose will usually come down to which offers the best long term health outcomes relative to the specific breed of your dog, and to an individual owner’s preferences in relation to behavioural issues (see below).

The procedures for OHE and OSS are quite similar. In both we will make an incision in the abdomen. This may be longer in an OSS operation, to allow the surgeon to see the whole uterus and gain access to the cervix. Incisions heal side to side not end to end so the longer incision for OSS will not affect your pet’s recovery time.

In the traditional OHE spay procedure the uterine horns, ovaries and the body of the uterus are removed. Because the uterus is no longer being stimulated by the ovaries there is no need to remove the entire uterus and the cervix is often left in.

An ovary-sparing spay differs in two important respects. First, the ovaries are left intact and functional, allowing them to continue to produce and regulate hormones in the same way as an unaltered dog. It is this naturally self-regulating hormone production that is now believed to be responsible for the decreased risk of long term health issues, including obesity, cardiac stress and urinary incontinence in the middle-aged spayed female, as well as greater longevity in females who have undergone OSS rather than OHE.

Secondly, the retention of the ovaries means that, in the OSS procedure, not only must the entire uterus to below the cervix be removed, the cervix must be cut and tied off (ligated) much more precisely than is generally necessary in a traditional spay, where ligation can be made almost anywhere on the uterus.

Precisely cutting and tying off the cervix rather than the uterus eliminates the risk of pyometra — an infection in the uterus that occurs as a result of hormonal changes in the female’s reproductive tract — and also avoids excessive tension on the supporting structures of the ovaries. The extra care required in an OSS adds a little time to the procedure compared with OHE but, for a surgeon familiar with the OSS technique, this time difference is quite minor.

There are some downsides to OSS. The retention of functioning ovaries brings with it a risk of ovarian cancer. However, this form of cancer is rare enough that it seems extreme to remove the ovaries, with all the health issues that may cause, simply to eliminate something that is already low risk.

For most pet owners the biggest negative of OSS will be behavioural issues. Although the female dog is sterile she will continue to show some of the normal sexual behaviours associated with an unaltered female. She will retain her heat cycles and will remain attractive to entire male dogs. In our experience most owners find these manageable. She will have little to no vaginal discharge during heat cycles for example.

The pros and cons of OHE versus OSS are listed below for comparison. Alpine Animal Doctors are always happy to discuss the relative merits of each with you, and recommend the procedure that’s best for you based on your circumstances and the age and breed of your pet.1

Advantages of retaining the ovaries (OSS)2

Can be carried out early without risk to future growth, particularly in larger breeds.

Lower incidence of hemangiosarcoma (cancer usually found in the spleen or heart).

Lower incidence of osteosarcoma (bone cancer).

Lower risk of transitional cell carcinoma (bladder cancer).

Lower incidence of urinary incontinence and urinary tract infection

Lower incidence of obesity in middle age.

Lower incidence of autoimmune thyroiditis and hypothyroidism.

Reduced incidence of cranial cruciate rupture.

Reduced incidence of hip dysplasia.

Lower incidence of adverse reactions to vaccines.

Decreased incidence of cognitive dysfunction.

Less aggression towards people and animals.

Evidence of increased lifespan in females left intact past puberty.

Disadvantages of retaining the ovaries (OHE)

Increased risk of mammary (breast) cancer, one of the most common types of cancer in small animals. Mammary neoplasia is malignant less than 50% of the time in dogs, and few dogs die from breast cancer due to low metastatic rates and early detection and treatment.

Increased risk of ovarian cancer (the incidence and mortality risk for ovarian cancer are very low).

Increased risk of wandering.

Ongoing sexual behaviours, including heat cycles.

For additional information, see At what age should I have my pet desexed? and Castration or Vasectomy — which one is right for my dog?

1Although surgical or anaesthesia complications or adverse outcomes are extremely rare in these operations no surgical procedure carried out under a general anaesthetic is entirely without risk. These will be fully explained to you prior to your pet undergoing surgery.

2The health advantages listed have been observed and reported in both intact female dogs and in females that have undergone OSS. They are generally thought to be related to the retention of the ovaries and the continued production of the sex steroid hormones in a naturally regulated way. Not all of these advantages will necessarily manifest themselves in all dogs who undergo an ovary-sparing spay procedure.

Castration vs Vasectomy

In male dogs sperm is produced in the testicles and carried, via a tube called the vas deferens, to the outside to fertilise the female. To be effective a neutering procedure must either completely prevent the production of sperm, or stop viable sperm from reaching the female.

Castration stops sperm being produced by the surgical removal of the testicles, through a skin incision either behind or just in front of the scrotum in dogs, or over the scrotum in cats.

Vasectomy is a slightly more complex procedure than castration, requiring a small incision in the scrotum and the removal, cutting or clamping of a portion of the vas deferens, preventing sperm from travelling outside the body. The sperm produced in the testicles is reabsorbed by the body.

Both procedures are quick, safe, entail minimal trauma for the animal and carry very little risk of surgical complications.1 Both render the animal sterile and incapable of reproducing. The main difference is that a vasectomy leaves the testicles intact within the scrotum and still capable of producing testosterone.

There are advantages and disadvantages to both castration and vasectomy, some of which differ depending on the age and breed of your pet. The more important pros and cons are listed below but to make a fully informed decision you should always discuss the options with your veterinarian.

Advantages of castration

No risk of testicular tumours (testicular cancer is fairly common in older males but malignancy and mortality are very low).</p

May reduce inter-dog aggression related to availability of intact females. NB: Forms of aggression unrelated to sexual behaviour, e.g., aggression caused by fear, timidity or poor socialisation, will not be reduced.

Reduced risk of roaming.

Reduced incidence of urinary marking.

Advantages of vasectomy2

Can be carried out prior to puberty without risk to future growth, particularly in larger breeds.

Lower incidence of hemangiosarcoma (cancer usually found in the spleen or heart).

Lower incidence of osteosarcoma (bone cancer).

Lower risk of transitional cell carcinoma (bladder cancer).

Lower risk of prostatic adenocarcinoma (prostate cancer).

Lower incidence of obesity in middle age.

Lower incidence of autoimmune thyroiditis and hypothyroidism.

Reduced incidence of cranial cruciate rupture.

Reduced incidence of hip dysplasia.

Lower incidence of adverse reactions to vaccines.

Decreased incidence of cognitive dysfunction.

Disadvantages of castration

If carried out too early castration can disrupt normal growth patterns, affecting long term health and longevity in some breeds. Dogs castrated before puberty may have longer limbs, lighter bone structure, narrow chests and narrow skulls. This abnormal growth may be avoided if castration is delayed until after growth plates fully close, i.e., when physical maturity is reached. This may mean waiting until your dog is as much as 2 years old, during which time your pet will be fertile.

Increased incidence of perineal and inguinal hernia and perineal adenoma.

Possibility of increased inter-dog aggression.

Increased risk of roaming.

Increased incidence of urinary marking.

Retention of testes and the consequent production of sex steroid hormones may lead to ongoing sexual behaviours similar to those of a fully intact male dog.

For additional information, seeOHE or OHS — which is best for my female dog? and At what age should I have my pet desexed?

1Although surgical or anaesthesia complications or adverse outcomes are extremely rare in these operations no surgical procedure carried out under a general anaesthetic is entirely without risk. These will be fully explained to you prior to your pet undergoing surgery.

2The health advantages listed have been observed and reported in both intact male dogs and in animals that have undergone a vasectomy. They are generally thought to be related to the retention of the testes and the continued production of the sex steroid hormones in a naturally regulated way. Not all of these advantages will necessarily manifest themselves in all dogs who undergo vasectomy procedures.

Keep Spot Safe

Keep Spot Safe is a community initiative by Alpine Animal Doctors that aims to see every pet in the Alpine Shire microchipped so they can be reunited with their family if they get lost.

There are almost six million pet dogs and cats in Australia. Every year thousands go missing. People move and Spot or Kitty decide the new place is not to their liking and set off to head back ‘home.’ They’re frightened by fireworks or thunderstorms and run away, to become lost and confused.

All too often these lost pets never find their families again, ending up at Council Pounds or animal shelters. Some may be rehomed but for many their fate will be euthanasia. The lucky ones — those whose owners had the foresight to have them microchipped — are quickly returned to their families.

Implanting a microchip should be one of the first things you do when you bring a new animal into your home. In fact, it’s a legal requirement in most states. From 1 January 2012 microchipping has been compulsory for all dogs across the whole of Australia, but microchipping legislation generally applies only to dogs and cats, and only to those born after the introduction of the legislation. That still leaves many thousands unprotected.

At Alpine Animal Doctors we have an ongoing program that aims to see every pet in the Shire — from Myrtleford to Mt Beauty — microchipped by 2018. This is not about revenue for our practice. Vets don’t make money from microchips, the low one-off lifetime fee really only covers the costs. It’s about protecting all of those who can’t protect themselves.

Put simply, if every animal owner had their pets chipped, and kept their registry details up to date when they moved house, we might never again see a stray dog or cat have to be put down because we can’t find their owners.

Microchipping is an extremely simple, safe and inexpensive procedure. Just call the hospital and we’ll do the rest.

This page was updated December 2016. The artwork featured is from the Deviantart community and was created by Devianart member Brandimuffin. Copyright is owned by the artist. Please do not download or share it. It is reproduced here under a CC license. You can find the original and other work by Brandimuffin here.

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